In This Issue:
- President’s Message
- ACEP and AAEM Liability Scores for Emergency Medicine Practice
- Illinois Update
- Indiana Update
- Iowa Update
- Resident Corner
Michael C. Walters, MD FAAEM
President, GLAAEM Board of Directors
With much excitement, I would like to welcome you to the newly formed Great Lakes State Chapter of AAEM (GLAAEM). We started the process of re-forming the state chapter in Wisconsin a few years ago. During the process, Mike Pulia, MD FAAEM, had the excellent idea of forming a regional chapter. The notion of a regional chapter had several attractive attributes, including numbers and talent. Hence, our chapter was born. We continued working on the foundation for the chapter at Scientific Assemblies in Las Vegas two years ago and in New York this past year. (Side note: many have been helpful along the way, but Drs. Otero and Baliga deserve special mention. I could not have done the work alone and they have been indispensable). We could have called ourselves the Big Ten State Chapter but we would have had to include Nebraska, Maryland, Pennsylvania, and New Jersey. I guess we could have gone with the ‘Original Big Ten.’ Even “Great Lakes” does not truly describe our membership since Iowa is part of our chapter despite not touching one of these beautiful bodies of water. Regardless of its shortcomings, our name captures the spirit of a region with shared ideals and similar challenges. The goals of the chapter are to promote “the integrity of the practice and management of emergency medicine (EM) in all clinical and administrative settings” within our states and be a resource for our membership at the local level. The unique aspect of our chapter requires a unique structure. The result is a chapter board of directors consisting of a president, vice president, secretary-treasurer, and one representative from each member state. The officers include: myself (president) from Wisconsin, Ronny Otero (vice president) from Michigan, and Sudhir Baliga (secretary-treasurer) from Michigan. The state representatives include: Caroline Pace (Wisconsin), Dipul Patadia (Illinois), Christopher Wood (Indiana), Joshua Pruitt (Iowa), and Robert Hoogstra (Michigan). Presently we are still looking for representatives for Minnesota and Ohio. Finally, two resident members will complete the board of directors. They are Chase Deobald (Medical College of Wisconsin) and Jayna Gardner-Grey (Henry Ford).
As previously mentioned, GLAAEM’s mission is to promote “the integrity of the practice and management of emergency medicine in all clinical and administrative settings.” One of the unique challenges of our states is the rural setting in which many of us practice. Given this feature, the promotion and support of rural emergency medicine will be an area of focus for GLAAEM. This is in addition to general EM promotion, support for our residency programs, and EM advocacy. Within our mission is the statement that “the practice of emergency medicine is best conducted by a specialist in emergency medicine.” This is true regardless of practice location. So why include the discussion of rural emergency medicine in this ingurial newsletter? The answer lies in the recent debate swirling around the American College of Emergency Physicians’ membership and our mission statement. In a recent publication, Dr. Richard Bukata used Iowa as an example of why non-residency trained or non-board certified emergency physicians should be allowed membership into the American College of Emergency Physicians.1 While ACEP’s membership is not our issue, the issue of who should be staffing rural emergency departments is our issue. Dr. Mark Reiter, our national president, highlighted some of the challenges facing rural emergency medicine in his rebuttal to Dr. Bukata.2 These challenges include the promotion of rural emergency medicine as a valuable and professional rewarding career path within our specialty and money. Within residencies rural emergency medicine is often not promoted as a desirable career path. Many times the result is residents viewing rural opportunities with skepticism or disdain, making recruitment very hard for rural hospitals. In terms of money, many times smaller, rural hospitals are unwilling to invest in board certified emergency physicians due to the higher cost than non-boarded physicians. They simply fail to see the value, both tangible and intangible, that board certified emergency physicians provide. The answer to the problems of rural emergency medicine staffing is not simply allowing anyone to work in these environments and obtain legitimacy with professional society membership. The answers are to: promote the professionally rewarding nature of rural emergency medicine so that more residents chose the career path, promote the value of board certified emergency physicians to rural hospital administrators, and promote the rural emergency physician within our specialty as a practitioner with unique skills and practice challenges not seen in larger urban or suburban centers. My belief is that as a chapter if we work on these answers, than the solution that Dr. Bukata raises will become irrelevant irrespective of a professional society’s decisions. AAEM has always maintained that emergency medicine should be practiced by emergency physicians. This should be true regardless of location. Our standards should not be allowed to slide simply due to location or lack of manpower. Our rural patients deserve high quality emergency care provided by trained emergency physicians as much as our urban patients.
Finally, this is your chapter. We welcome ideas, suggestions, criticisms, and comments. Our chapter will grow based on the strength of our membership. So please encourage your colleagues to join and become involved. We look forward to an active chapter and to provide value and service to our members. Part of that value will be a bi-monthly e-newsletter to update members on issues in our states. So, welcome to the inaugural e-newsletter of GLAAEM and I hope you enjoy.
- Bukata R. Open wide the gates. Emergency Physician Monthly. June 2014; 21(6).
- Reiter M. Expanding legitimacy for non-certified docs — A step in the wrong direction. Emergency Physician Monthly. July 2014; 21(7).
Ronny M. Otero, MD FAAEM
Vice President, GLAAEM Board of Directors
As practitioners in one of the “high-risk specialties,” emergency physicians are familiar with the procedures and diagnoses that can lead to medical liability cases.1 However, it would also be sensible to become familiar with the liability climate in the state in which they practice or plan on practicing in the near future.
In January 2014, the American College of Emergency Physicians published the third iteration of the National Emergency Medicine Report Card.2 This report card grades access to emergency care, quality/patient safety, medical liability, public health/injury prevention, and disaster preparedness. The report card is published to provide an overview of the practice climate and support for emergency care at a state and national level. Each category receives a grade from “A” to “F”. A few months prior to the release of the ACEP report card, the legal committee of AAEM represented by Dr. Gregory Roslund carefully researched the current liability environment similarly in a state-by-state fashion to be published in five parts.3 The series does an excellent job of defining key legal terms with which emergency physicians should be familiar in order to understand issues of medical liability including the difference between hard caps and soft caps, non-economic damages, collateral source rules, joint and several liability, and expert witness reform to name a few. States are rated from one to five stars based upon the level of tort reform, liability expenses, and other parameters.
The series began in the July/August 2013 issue of Common Sense as Part 1 Alabama-Florida, Part 2 Georgia-Maine, Part 3 Maryland-North Dakota, Part 4 Ohio-Rhode Island, and Part 5 South Carolina-Wyoming in the September/October 2014 issue. In this series, Dr. Roslund shares some insight regarding the overall litigation climate in specific states. The following is a summary and comparison of how the “ACEP Report Card” and the “AAEM Medical Liability and Emergency Physician: A State-by-State Comparison” rate the medical liability climates in the states represented by the Great Lakes American Academy of Emergency Medicine (GLAAEM) (Illinois, Indiana, Iowa, Michigan, Minnesota, Ohio and Wisconsin). The ACEP rank for the state appears first followed by the letter grade received for that category, then the trend since the 2009 “Report Card.” The AAEM rating follows the ACEP grade with a comment regarding specific issues regarding liability in the state.
- ACEP: Medical Liability Rank 50, Grade F (worse from D)
- AAEM: 0.5 Stars out of 5. Illinois has no caps for damages. Caps have been voted down on a couple of occasions.
- ACEP: Medical Liability Rank 23, Grade C (improved from D+)
- AAEM: 4.75 stars out of 5. Indiana enjoys “no joint and several liability” reforms, but does suffer from weak expert witness reform, and no specific language to protect emergency physicians.
- ACEP: Medical Liability Rank 27, Grade C (improvement from D)
- AAEM: 3.5 stars out of 5. Iowa is a state with a historically low litigation rate but there has been little if any malpractice reform. There is a lack of caps on damages. It does have joint and several liability reforms; there is a two-year statute of limitations and a soft limit on attorney fees. Iowa enjoys relatively low annual malpractice premiums.
- ACEP: Medical Liability Rank 6, Grade B+ (improvement from C)
- AAEM: 4 stars out of 5. There is a $350,000 cap on non-economic damages and up to $500,000 on catastrophic or multiple plaintiffs. Four-year statute of limitations, proportionate liability reform (damages rated based on plaintiffs share of negligence), case certification by expert, and peer review protection.
- ACEP: Medical Liability Rank 33, Grade D (improvement from D-)
- AAEM: 2.75 out of 5 stars. There are graded caps on non-economic caps based upon the level of injury from $280,000 to $500,000. No joint and several liability reforms, high premiums. A bill being floated around is HB 4354, which would increase the burden of proof in cases involving emergency physicians.
- ACEP: Medical Liability Rank 13, Grade B- (improvement from C-)
- AAEM: 3.5 stars out of 5. Low malpractice premiums, but an overall low litigation rate. There are no caps on damages, no limits on attorney fees and no substantial expert witness reform
- ACEP: Medical Liability Rank 18, Grade C+ (unchanged from C+)
- AAEM: 4.25 out of 5 stars. Hard cap set at $750,000, relatively low malpractice costs, and is a state that has a “patient compensation fund” which pays out settlements not covered by doctors malpractice coverage. Their Apology Law is designed to protect physicians who make a statement of empathy or sympathy by not allowing the statement to be admissible. (Of the other states represented by GLAAEM only Indiana, Iowa, Michigan and Ohio also have “apology laws”.) Though Wisconsin has enjoyed fairly robust malpractice reforms there has not been significant change in expert witness reform.
The information provided is a summary of what is contained in the ACEP report card and the AAEM Medical Liability series. Readers are directed to the original sources to familiarize themselves with details about the sources of information used to conduct these studies. We believe this type of information is useful to our membership as it may affect practice, job selection, and recruitment.
- Carroll AE, Buddenbaum JL. High and low-risk specialties experience with the U.S. medical malpractice system. BMC Health Services Research 2013, 13:465
- www.emreport.org accessed August 1, 2014
- http://www.aaem.org/publications/common-sense/medical-liability-state-by-state accessed August 1, 2014
Dipul Patadia, MD MBA FAAEM
Illinois State Representative, GLAAEM Board of Directors
Remember the good Ol’ Days…
When you might actually get some shut-eye on a night shift?
When grilling burgers out in the ambulance bay was routine?
When you cared about your patients because you were simply a doctor and not looking to improve your patient satisfaction score?
When metrics was a term that only business analysts used on Wall Street?
When the emergency department had a core group of physicians, nurses, and techs that worked in the ED for the same hospital until they retired?
When time was spent with patients and their families instead of in front of a computer?
When you could do the “right” thing for the patient without the fear of lawsuits or administrative deficiencies?
Unfortunately, I did not practice during this wonderful time of medicine. However, as I hear these phrases uttered in the walls of emergency departments across the country by seasoned, skilled practitioners, I wonder if we will hope to achieve some of the “greatness that once was.”
The art of medicine has changed in many ways. We provide efficient care, but have we cut down obstacles for patients after they have left the ED? We speak, but are our patient’s listening? We treat, but do we heal?
As technology continues to transform the world in which we care for our patients, our ability to heal should theoretically improve. I don’t doubt that we have improved our tools to help our patients, but have we improved our culture of caring?
As we race into and out of patient rooms, checking the clock, fumbling to find orders on our screens, talking to the million and one consultants that are on each case, we sometimes forget about how we react to the people working around us who are equally committed to our patients.
Most people in emergency medicine did not go into it for the glory! From the alcoholic yelling at staff at 3am to the moaning demented nursing home resident to the countless indigent patients, we are the last line of defense. We trudge into the ED at all hours of the day in an attempt to help people who emotionally or physically need our attention. We are soldiers of humanity and are the last savior in a world of governmental and insurance related red tape. We have the privilege of treating people whose lives hang in the balance. I can’t begin to count the number of phone calls from families, friends, and others in the communities who we help advise. We sacrifice ball games, piano recitals, family gatherings, holidays all in the name of 24-hour care.
Although I cannot turn back the clock, I can always still be proud of what we do for our patients.
Years from now, I hope to look back and rather than speak with negativity on the hurdles we experience practicing emergency medicine, I would like to say…
Remember the good Ol’ Days…
When I helped a first time mother sleep quietly knowing her child was well?
When I actually helped the one out of a thousand alcoholics quit drinking?
When I held hands with family members of a dying patient?
When I welcomed a homeless man on a sub-zero temperature night with a smile and a warm blanket?
When I was invited into stories of patients’ lives while stitching their wounds?
When I helped save a kid from meningococcemia who came back to say thank you and then went on to become a nurse?
When I worked with a team of professionals with whom I laughed and relied upon in those never ending long nights?
When I cared about the patients I treated because they needed me?
Christopher Wood, MD FAAEM
Indiana State Representative, GLAAEM Board of Directors
Medicaid Expansion and HIP 2.0
Traditionally, Medicaid insurance has covered specific low-income groups (the disabled, elderly, pregnant women, and children). Prior to the Affordable Care Act (ACA), many individuals were not eligible for Medicaid, and families were only eligible at <50% of the federal poverty level (FPL). In Indiana, for example, jobless and working parents were only eligible with incomes at 18 and 24% of FPL, respectively.1
The passage of the ACA initially mandated that states expand Medicaid insurance coverage. Beginning January 1 of this year, the ACA increased Medicaid eligibility to adults and families at <138% of the FPL.2 However, the June 2012 Supreme Court decision (NFIB v. Sebelius) ruled that states could opt out of this Medicaid expansion.3 In states where Medicaid expansion has been opposed, governors of these states started searching for alternatives to provide coverage options for low-income, non-pregnant and non-disabled adults.
In 2008, Indiana established the Healthy Indiana Plan (HIP) to provide insurance coverage for low-income adults without access to employer-based coverage, Medicare, or traditional Medicaid, operating under a federally approved Medicaid waiver.4, 5 The plan combined elements of a high-deductible plan and health savings account (HSA), along with preventative care services not subject to deductibles or deduction from the HSA. It also included co-pays for “inappropriate” ED visits (up to $25). Touted as a consumer-driven health care plan, the state has boasted of several successes from the program, including reduced “inappropriate” ED visits, increased use of urgent care and primary care for acute care visits, increased utilization of preventative care services, increased use of generic drugs, and high member satisfaction.6
In response to the ACA and the NFIB v. Sebelius decision, Indiana Governor Mike Pence has proposed expansion of HIP to replace traditional Medicaid for all non-disabled adults.7 HIP 2.0 will provide a coverage option for adults 19-64 with incomes up to 138% of FPL (for 2014 equals $16,105 for individuals or $32,913 for a family of four). The program will be funded through Indiana’s cigarette tax and Hospital Assessment Fee, in addition to federal Medicaid funding.
The plan continues the precedent of the original Healthy Indiana Plan, utilizing a combination of a high-deductible plan and a HAS (called a Personal Wellness Responsibility (POWER) account) to help pay for deductible expenses. There are three pathways to coverage under HIP 2.0:
With HIP 2.0, maternity coverage is included. Previous annual and lifetime coverage limits will be removed. The co-pay for “inappropriate” ED utilization will remain in place.8 There are also penalties for those who do not contribute to their POWER accounts.
The proposed plan also promises physicians improve reimbursement vs. traditional Medicaid, with reimbursement rates “closer to 100% of Medicare rates.9” The proposed plan promises improved provider participation as a result of improved reimbursement, thus improving access to care for plan participants.10
Governor Pence’s initial goal is to expand coverage to 350,000 Indiana residents with this plan.
After the initial proposal was presented, a 30-day public comment period ensued, ending in June of this year. Public comments were generally supportive of the proposal, and included support from the Indiana Hospital Association, Indiana State Medical Association, and “numerous hospitals.”11 Some of these entities supported the HIP program’s emphasis on decreasing ED use and improved use of preventative care, along with improved cost-conscious consumer behavior. The Indiana Hospital Association wrote that “HIP 2.0 contains the right mix of incentives that will allow us to move the front door to the health care system from the emergency room to a primary care physician’s office.”11 There was also support for proposals for improved reimbursement rates and decreases in cost-shifting to the private market.11
Since the closure of the public comment period, the state has submitted an application to CMS for a Medicaid waiver that will allow the state to move forward with the plan. Although CMS has no required timeline for approval, the state is hopeful that implementation can begin as early as 2015.12
- http://jama.jamanetwork.com/article.aspx?articleid=1672246 (JAMA, March 27, 2013—Vol 309, No. 12 1219)
Joshua Pruitt, MD FAAEM
Iowa State Representative, GLAAEM Board of Directors
For this inaugural newsletter of GLAAEM, I guess an introduction would be in order. My name is Josh Pruitt and I completed medical school at East Tennessee State Quillen College of Medicine in 2007. I did my emergency medicine residency at the University of Iowa, completing this in 2010. I have been a partner with East Central Iowa Acute Care, LLP, since 2011. We provide emergency department coverage to five hospitals, one with >50,000 annual visits and four rural critical access hospitals. I look forward to hearing from you regarding how GLAAEM can serve you better. Let me know about issues as they arise, whether it is an advocacy issue with the state legislature or an educational issue. This is your organization, and I’m here to ensure you are benefited appropriately. You can reach me by email (firstname.lastname@example.org) or phone (319-899-2794).
Chase Deobald, DO
Resident Representative, GLAAEM Board of Directors
Welcome fellow GLAAEM emergency medicine (EM) residents! I’m helping to promote the resident perspective during board meetings for GLAAEM, keep you updated on upcoming educational opportunities, and as always, find ways in which our local chapter can help you during the busy time of residency. My goal is to entertain you a bit with posts and have a few great educational points each month. Everyone is certainly busy at this time (which I am learning will never change), but hopefully I’ll find an article every month that you might have missed. I’m always open for suggests, so please reply at email@example.com.
Great starting points for the Resident Corner articles are really defining AAEM and GLAAEM. In the landscape of national organizations, academic journals, and endless emails that were supposed to be filtered by Gmail but slipped through for the thousandth time, it’s hard to truly filter out the noise and focus on the organizations that you really care about (sound like a busy night in the ED?). Briefly, AAEM was founded in 1993 to promote a fair practice environment for emergency physicians and has since worked diligently to uphold the standard of care in emergency medicine. That discussion always revolves around completing EM residency and board certification. As a resident in a board certified program you really are receiving a focused practice pattern that cannot be replicated in any other specialty training program. AAEM wants to protect your rights as well as your patients!
AAEM is actively limiting consolidation of large EM physician groups in hopes of keeping practicing physicians free of profit-focused corporate business structure. It is vital to be aware of this consolidation trend as you search for your first job (and all future jobs) out of residency. 1 GLAAEM, on the other hand, continues this fight at the local level. We hope to keep you up to speed on the changes in your region (think of the different practice environment in Texas with the rise of free standing emergency departments).2
Final thoughts: EM is growing in popularity among graduating medical students (and who can blame them? We R-O-C-K!). The health care environment is changing rapidly with a lot of changes in policy, reimbursement, and the continued growth of patient volume.3 We are the future of EM and must bear the tide of outside influence from corporate structure, efficiency standards, and yet still focus on building our knowledge base to make the best decision for our individual patient each and every shift. Good luck in your training!
- “AAEM History.” American Academy of Emergency Medicine. N.d. Web.
- Galewitz P. “ ‘Wildfire’ Growth Of Freestanding ERs Raises Concerns About Cost.” Kaiser Health News. Web. 15 July 2013.
- Smulowitz PB, O’Malley J, Yang X, Landon BE. Increased Use of the Emergency Department After Health Care Reform in Massachusetts. Annals of Emergency Medicine. August 2014; 64(2): 107-115.
Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM, its chapter divisions or affiliates. These articles are intended for the individual use of AAEM members.